1. (1) A person-centered service plan must be developed through a person-centered service planning process. The person-centered service planning process:

   1. (a) Is directed by the resident;
   2. (b) Includes people chosen by the resident;
   3. (c) Provides necessary information and support to ensure the resident directs the process to the maximum extent possible and is enabled to make informed choices and decisions, except as limited or required by a court order, an administrative order, the supervisory entity or the resident’s legal representative, if applicable;
   4. (d) Reflects the services and supports, and delivery of those services and supports in a manner that is important to the resident;
   5. (e) Is timely, responsive to changing needs, occurs at times and locations convenient to the resident, and is reviewed by the resident and the resident’s legal representative, if applicable, every ninety (90) days or more often as determined by the resident;
   6. (f) Reflects the cultural considerations and values of the resident;
   7. (g) Uses language, format, and presentation methods appropriate for effective communication according to the needs and abilities of the resident and the resident’s legal representative as applicable;

   8. (h) Includes strategies for resolving disagreement within the process including clear conflict of interest guidelines for all planning participants such as:

      1. (A) Discussing the concerns of the planning team members and determining acceptable solutions;
      2. (B) Supporting the resident in arranging and conducting a person-centered service planning meeting;
      3. (C) Utilizing any available greater community conflict resolution resources;
      4. (D) Referring concerns to the Oregon Residential Facilities Ombudsperson; or

      5. (E) Following existing, program-specific grievance processes.

         1. (i) Offers choices to the resident regarding the services and supports the resident receives and from whom and records the alternative HCBS settings considered by the resident, except as limited by a court, OHA, CMHP, or PSRB order;
   9. (j) Provides a method for the resident or the resident’s legal representative, if applicable, to request updates to the person-centered service plan;
   10. (k) Is conducted to reflect what is important to the resident to ensure delivery of services in a manner reflecting personal preferences and ensuring health and welfare;
   11. (l) Identifies the strengths and preferences, service and support needs, goals, and desired outcomes of the resident;
   12. (m) Includes any resident identified goals and preferences related to relationships, greater community participation, employment, income and savings, healthcare and wellness, and education;

   13. (n) Includes risk factors and plans to minimize any identified risk factors, including:

       1. (A) Identification of back-up plans as needed; and
       2. (B) Identification of procedures to follow when the primary provider is unable to deliver necessary services; and
   14. (o) Results in a person-centered service plan documented by the person-centered services plan coordinator, signed by the resident or the resident’s legal representative, if applicable, the resident’s care coordinator, and all persons responsible for the implementation of the person-centered service plan, and implemented by the provider. The person-centered service plan must be distributed to the resident, the resident’s legal representative or the supervisory entity if applicable, and other people involved in the person-centered service plan.

2. (2) Person-Centered Service Plans:

   1. (a) To avoid conflict of interest, the person-centered service plan may not be developed by the provider.

   2. (b) The person-centered service plan includes the following:

      1. (A) HCBS and setting options based on the resident's needs and preferences, and for residential settings, the resident's available resources for room and board;
      2. (B) The HCBS and settings are chosen by the resident and are integrated in, and support full access to the greater community;
      3. (C) Opportunities to seek employment and work in competitive integrated employment settings for those residents who desire to work. If the resident wishes to pursue employment, a non-disability specific setting option must be presented and documented in the person-centered service plan;
      4. (D) Opportunities to engage in greater community life, control personal resources, and receive services in the greater community to the same degree of access as people not receiving HCBS;
      5. (E) The strengths and preferences of the resident;
      6. (F) The service and support needs of the resident;
      7. (G) The goals and desired outcomes of the resident;
      8. (H) The providers of services and supports including unpaid natural supports provided voluntarily and other alternative resources;
      9. (I) Risk factors and measures in place to minimize each identified risk;
      10. (J) Individually based limitations that limit or restrict HCBS settings to keep the resident and others safe from harm;
      11. (K) Individualized backup plans and strategies, when needed;
      12. (L) People who are important in supporting the resident;
      13. (M) The person responsible for monitoring the person-centered service plan;
      14. (N) Language, format, and presentation methods appropriate for effective communication according to the needs and abilities of the resident receiving services and the resident’s legal representative, if applicable;
      15. (O) The written informed consent of the resident or the resident’s legal representative or supervisory entity, if applicable, indicating agreement with the information, services and supports identified;
      16. (P) Signatures of the resident or the resident’s legal representative or supervisory entity, if applicable, or documentation of the resident’s verbal consent of services, participants in the person-centered service planning process, and all providers responsible for the implementation of the person-centered service plan; and
      17. (Q) Provisions to prevent unnecessary or inappropriate services and supports.
   3. (c) The provider must provide relevant information and provide necessary support for the person-centered service plan coordinator or other persons developing the plan to fulfill the characteristics described in subsection (b) of this section;
   4. (d) The resident or the resident’s legal representative if applicable, decides on the level of information in the person-centered service plan that is shared with providers. To effectively provide services, providers must have access to the portion of the person-centered service plan that the provider is responsible for implementing;
   5. (e) The person-centered service plan must be distributed to the resident and the resident’s legal representative and supervisory entity, as applicable, and others involved in the person-centered service plan;
   6. (f) The person-centered service plan must justify and document any individually-based limitation(s) to be applied as described in OAR 410-173-0040 when the conditions described in OAR 410-173-0035(1)(d) and (2)(d-j) may not be met due to threats to the health and safety of the resident or others; and
   7. (g) The person-centered service plan must be reviewed with and revised as directed by the resident or the resident’s legal representative, if applicable, every ninety (90) days or more often as determined by the resident as described in OAR 410-173-0025 (1).

   8. (h) The person-centered service plan must be reviewed and revised:

      1. (A) At the request of the resident or the resident’s legal representative;
      2. (B) When the circumstances or needs of the resident change; and
      3. (C) At least annually and upon reassessment of functional needs as described in OAR 410-173-0025 (3).

Statutory/Other Authority

ORS 413.042 & 443.450

Statutes/Other Implemented

ORS 413.032, 443.400 - 443.465 & 443.991

History

BHS 6-2026, amend filed 04/30/2026, effective 05/01/2026
BHS 5-2026, amend filed 04/30/2026, effective 06/01/2026
BHS 32-2025, temporary amend filed 12/30/2025, effective 01/01/2026 through 06/27/2026
BHS 4-2025, amend filed 02/28/2025, effective 03/01/2025
BHS 6-2024, amend filed 04/11/2024, effective 04/11/2024
BHS 41-2023, temporary amend filed 10/12/2023, effective 10/15/2023 through 04/11/2024
BHS 6-2020, temporary amend filed 04/21/2020, effective 04/21/2020 through 10/09/2020
MHS 5-2017, f. & cert. ef. 6-8-17
MHS 2-2017(Temp), f. 3-3-17, cert. ef. 3-4-17 thru 8-30-17
MHS 13-2016(Temp), f. 9-6-16, cert. ef. 9-7-16 thru 3-3-17
MHS 4-2008, f. & cert. ef. 6-12-08
MHD 4-2005, f. & cert. ef. 4-1-05
MHD 4-1998, f. 5-21-98, cert. ef. 6-1-98
MHD 9-1985, f. & ef. 6-7-85
MHD 9-1984(Temp), f. & ef. 12-10-84